<?php
/* @var $this GnuhealthPatientController */
/* @var $model GnuhealthPatient */
/* @var $form CActiveForm */
?>

<div class="form">

<?php $form=$this->beginWidget('CActiveForm', array(
	'id'=>'gnuhealth-patient-form',
	// Please note: When you enable ajax validation, make sure the corresponding
	// controller action is handling ajax validation correctly.
	// There is a call to performAjaxValidation() commented in generated controller code.
	// See class documentation of CActiveForm for details on this.
	'enableAjaxValidation'=>false,
)); ?>

	<p class="note">Fields with <span class="required">*</span> are required.</p>

	<?php echo $form->errorSummary($model); ?>

	<div class="row">
		<?php echo $form->labelEx($model,'create_date'); ?>
		<?php echo $form->textField($model,'create_date',array('size'=>6,'maxlength'=>6)); ?>
		<?php echo $form->error($model,'create_date'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'write_date'); ?>
		<?php echo $form->textField($model,'write_date',array('size'=>6,'maxlength'=>6)); ?>
		<?php echo $form->error($model,'write_date'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'create_uid'); ?>
		<?php echo $form->textField($model,'create_uid'); ?>
		<?php echo $form->error($model,'create_uid'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'write_uid'); ?>
		<?php echo $form->textField($model,'write_uid'); ?>
		<?php echo $form->error($model,'write_uid'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'family'); ?>
		<?php echo $form->textField($model,'family'); ?>
		<?php echo $form->error($model,'family'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'photo'); ?>
		<?php echo $form->textField($model,'photo'); ?>
		<?php echo $form->error($model,'photo'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sex'); ?>
		<?php echo $form->textField($model,'sex'); ?>
		<?php echo $form->error($model,'sex'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'blood_type'); ?>
		<?php echo $form->textField($model,'blood_type'); ?>
		<?php echo $form->error($model,'blood_type'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'general_info'); ?>
		<?php echo $form->textArea($model,'general_info',array('rows'=>6, 'cols'=>50)); ?>
		<?php echo $form->error($model,'general_info'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'primary_care_doctor'); ?>
		<?php echo $form->textField($model,'primary_care_doctor'); ?>
		<?php echo $form->error($model,'primary_care_doctor'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'critical_info'); ?>
		<?php echo $form->textArea($model,'critical_info',array('rows'=>6, 'cols'=>50)); ?>
		<?php echo $form->error($model,'critical_info'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'rh'); ?>
		<?php echo $form->textField($model,'rh'); ?>
		<?php echo $form->error($model,'rh'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'current_address'); ?>
		<?php echo $form->textField($model,'current_address'); ?>
		<?php echo $form->error($model,'current_address'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ethnic_group'); ?>
		<?php echo $form->textField($model,'ethnic_group'); ?>
		<?php echo $form->error($model,'ethnic_group'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'name'); ?>
		<?php echo $form->textField($model,'name'); ?>
		<?php echo $form->error($model,'name'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'dob'); ?>
		<?php echo $form->textField($model,'dob'); ?>
		<?php echo $form->error($model,'dob'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'marital_status'); ?>
		<?php echo $form->textField($model,'marital_status'); ?>
		<?php echo $form->error($model,'marital_status'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'dod'); ?>
		<?php echo $form->textField($model,'dod',array('size'=>0,'maxlength'=>0)); ?>
		<?php echo $form->error($model,'dod'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'current_insurance'); ?>
		<?php echo $form->textField($model,'current_insurance'); ?>
		<?php echo $form->error($model,'current_insurance'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'cod'); ?>
		<?php echo $form->textField($model,'cod'); ?>
		<?php echo $form->error($model,'cod'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'identification_code'); ?>
		<?php echo $form->textField($model,'identification_code'); ?>
		<?php echo $form->error($model,'identification_code'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'deceased'); ?>
		<?php echo $form->checkBox($model,'deceased'); ?>
		<?php echo $form->error($model,'deceased'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'works_at_home'); ?>
		<?php echo $form->checkBox($model,'works_at_home'); ?>
		<?php echo $form->error($model,'works_at_home'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'prison_current'); ?>
		<?php echo $form->checkBox($model,'prison_current'); ?>
		<?php echo $form->error($model,'prison_current'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_score'); ?>
		<?php echo $form->textField($model,'fam_apgar_score'); ?>
		<?php echo $form->error($model,'fam_apgar_score'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'domestic_violence'); ?>
		<?php echo $form->checkBox($model,'domestic_violence'); ?>
		<?php echo $form->error($model,'domestic_violence'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'hostile_area'); ?>
		<?php echo $form->checkBox($model,'hostile_area'); ?>
		<?php echo $form->error($model,'hostile_area'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexual_abuse'); ?>
		<?php echo $form->checkBox($model,'sexual_abuse'); ?>
		<?php echo $form->error($model,'sexual_abuse'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sewers'); ?>
		<?php echo $form->checkBox($model,'sewers'); ?>
		<?php echo $form->error($model,'sewers'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'hours_outside'); ?>
		<?php echo $form->textField($model,'hours_outside'); ?>
		<?php echo $form->error($model,'hours_outside'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ses'); ?>
		<?php echo $form->textField($model,'ses'); ?>
		<?php echo $form->error($model,'ses'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'education'); ?>
		<?php echo $form->textField($model,'education'); ?>
		<?php echo $form->error($model,'education'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'television'); ?>
		<?php echo $form->checkBox($model,'television'); ?>
		<?php echo $form->error($model,'television'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'occupation'); ?>
		<?php echo $form->textField($model,'occupation'); ?>
		<?php echo $form->error($model,'occupation'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'drug_addiction'); ?>
		<?php echo $form->checkBox($model,'drug_addiction'); ?>
		<?php echo $form->error($model,'drug_addiction'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_timesharing'); ?>
		<?php echo $form->textField($model,'fam_apgar_timesharing'); ?>
		<?php echo $form->error($model,'fam_apgar_timesharing'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'electricity'); ?>
		<?php echo $form->checkBox($model,'electricity'); ?>
		<?php echo $form->error($model,'electricity'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'housing'); ?>
		<?php echo $form->textField($model,'housing'); ?>
		<?php echo $form->error($model,'housing'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'school_withdrawal'); ?>
		<?php echo $form->checkBox($model,'school_withdrawal'); ?>
		<?php echo $form->error($model,'school_withdrawal'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'income'); ?>
		<?php echo $form->textField($model,'income'); ?>
		<?php echo $form->error($model,'income'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'single_parent'); ?>
		<?php echo $form->checkBox($model,'single_parent'); ?>
		<?php echo $form->error($model,'single_parent'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ses_notes'); ?>
		<?php echo $form->textArea($model,'ses_notes',array('rows'=>6, 'cols'=>50)); ?>
		<?php echo $form->error($model,'ses_notes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_affection'); ?>
		<?php echo $form->textField($model,'fam_apgar_affection'); ?>
		<?php echo $form->error($model,'fam_apgar_affection'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'gas'); ?>
		<?php echo $form->checkBox($model,'gas'); ?>
		<?php echo $form->error($model,'gas'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'internet'); ?>
		<?php echo $form->checkBox($model,'internet'); ?>
		<?php echo $form->error($model,'internet'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'telephone'); ?>
		<?php echo $form->checkBox($model,'telephone'); ?>
		<?php echo $form->error($model,'telephone'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'water'); ?>
		<?php echo $form->checkBox($model,'water'); ?>
		<?php echo $form->error($model,'water'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_discussion'); ?>
		<?php echo $form->textField($model,'fam_apgar_discussion'); ?>
		<?php echo $form->error($model,'fam_apgar_discussion'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'working_children'); ?>
		<?php echo $form->checkBox($model,'working_children'); ?>
		<?php echo $form->error($model,'working_children'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_help'); ?>
		<?php echo $form->textField($model,'fam_apgar_help'); ?>
		<?php echo $form->error($model,'fam_apgar_help'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'trash'); ?>
		<?php echo $form->checkBox($model,'trash'); ?>
		<?php echo $form->error($model,'trash'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'teenage_pregnancy'); ?>
		<?php echo $form->checkBox($model,'teenage_pregnancy'); ?>
		<?php echo $form->error($model,'teenage_pregnancy'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'prison_past'); ?>
		<?php echo $form->checkBox($model,'prison_past'); ?>
		<?php echo $form->error($model,'prison_past'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'relative_in_prison'); ?>
		<?php echo $form->checkBox($model,'relative_in_prison'); ?>
		<?php echo $form->error($model,'relative_in_prison'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fam_apgar_decisions'); ?>
		<?php echo $form->textField($model,'fam_apgar_decisions'); ?>
		<?php echo $form->error($model,'fam_apgar_decisions'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'full_term'); ?>
		<?php echo $form->textField($model,'full_term'); ?>
		<?php echo $form->error($model,'full_term'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'colposcopy'); ?>
		<?php echo $form->checkBox($model,'colposcopy'); ?>
		<?php echo $form->error($model,'colposcopy'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'breast_self_examination'); ?>
		<?php echo $form->checkBox($model,'breast_self_examination'); ?>
		<?php echo $form->error($model,'breast_self_examination'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'pap_test'); ?>
		<?php echo $form->checkBox($model,'pap_test'); ?>
		<?php echo $form->error($model,'pap_test'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'mammography'); ?>
		<?php echo $form->checkBox($model,'mammography'); ?>
		<?php echo $form->error($model,'mammography'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'menopause'); ?>
		<?php echo $form->textField($model,'menopause'); ?>
		<?php echo $form->error($model,'menopause'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'stillbirths'); ?>
		<?php echo $form->textField($model,'stillbirths'); ?>
		<?php echo $form->error($model,'stillbirths'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'pap_test_last'); ?>
		<?php echo $form->textField($model,'pap_test_last'); ?>
		<?php echo $form->error($model,'pap_test_last'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'fertile'); ?>
		<?php echo $form->checkBox($model,'fertile'); ?>
		<?php echo $form->error($model,'fertile'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'colposcopy_last'); ?>
		<?php echo $form->textField($model,'colposcopy_last'); ?>
		<?php echo $form->error($model,'colposcopy_last'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'menopausal'); ?>
		<?php echo $form->checkBox($model,'menopausal'); ?>
		<?php echo $form->error($model,'menopausal'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'mammography_last'); ?>
		<?php echo $form->textField($model,'mammography_last'); ?>
		<?php echo $form->error($model,'mammography_last'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'abortions'); ?>
		<?php echo $form->textField($model,'abortions'); ?>
		<?php echo $form->error($model,'abortions'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'premature'); ?>
		<?php echo $form->textField($model,'premature'); ?>
		<?php echo $form->error($model,'premature'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'menarche'); ?>
		<?php echo $form->textField($model,'menarche'); ?>
		<?php echo $form->error($model,'menarche'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'gravida'); ?>
		<?php echo $form->textField($model,'gravida'); ?>
		<?php echo $form->error($model,'gravida'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexuality_info'); ?>
		<?php echo $form->textArea($model,'sexuality_info',array('rows'=>6, 'cols'=>50)); ?>
		<?php echo $form->error($model,'sexuality_info'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'smoking_number'); ?>
		<?php echo $form->textField($model,'smoking_number'); ?>
		<?php echo $form->error($model,'smoking_number'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexual_partners'); ?>
		<?php echo $form->textField($model,'sexual_partners'); ?>
		<?php echo $form->error($model,'sexual_partners'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'soft_drinks'); ?>
		<?php echo $form->checkBox($model,'soft_drinks'); ?>
		<?php echo $form->error($model,'soft_drinks'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'coffee'); ?>
		<?php echo $form->checkBox($model,'coffee'); ?>
		<?php echo $form->error($model,'coffee'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'exercise_minutes_day'); ?>
		<?php echo $form->textField($model,'exercise_minutes_day'); ?>
		<?php echo $form->error($model,'exercise_minutes_day'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexual_practices'); ?>
		<?php echo $form->textField($model,'sexual_practices'); ?>
		<?php echo $form->error($model,'sexual_practices'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ex_drug_addict'); ?>
		<?php echo $form->checkBox($model,'ex_drug_addict'); ?>
		<?php echo $form->error($model,'ex_drug_addict'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexual_preferences'); ?>
		<?php echo $form->textField($model,'sexual_preferences'); ?>
		<?php echo $form->error($model,'sexual_preferences'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'car_child_safety'); ?>
		<?php echo $form->checkBox($model,'car_child_safety'); ?>
		<?php echo $form->error($model,'car_child_safety'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'alcohol'); ?>
		<?php echo $form->checkBox($model,'alcohol'); ?>
		<?php echo $form->error($model,'alcohol'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ex_alcoholic'); ?>
		<?php echo $form->checkBox($model,'ex_alcoholic'); ?>
		<?php echo $form->error($model,'ex_alcoholic'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_start_drugs'); ?>
		<?php echo $form->textField($model,'age_start_drugs'); ?>
		<?php echo $form->error($model,'age_start_drugs'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'number_of_meals'); ?>
		<?php echo $form->textField($model,'number_of_meals'); ?>
		<?php echo $form->error($model,'number_of_meals'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'coffee_cups'); ?>
		<?php echo $form->textField($model,'coffee_cups'); ?>
		<?php echo $form->error($model,'coffee_cups'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'exercise'); ?>
		<?php echo $form->checkBox($model,'exercise'); ?>
		<?php echo $form->error($model,'exercise'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sex_with_prostitutes'); ?>
		<?php echo $form->checkBox($model,'sex_with_prostitutes'); ?>
		<?php echo $form->error($model,'sex_with_prostitutes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sleep_during_daytime'); ?>
		<?php echo $form->checkBox($model,'sleep_during_daytime'); ?>
		<?php echo $form->error($model,'sleep_during_daytime'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_quit_smoking'); ?>
		<?php echo $form->textField($model,'age_quit_smoking'); ?>
		<?php echo $form->error($model,'age_quit_smoking'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'ex_smoker'); ?>
		<?php echo $form->checkBox($model,'ex_smoker'); ?>
		<?php echo $form->error($model,'ex_smoker'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'lifestyle_info'); ?>
		<?php echo $form->textArea($model,'lifestyle_info',array('rows'=>6, 'cols'=>50)); ?>
		<?php echo $form->error($model,'lifestyle_info'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'car_seat_belt'); ?>
		<?php echo $form->checkBox($model,'car_seat_belt'); ?>
		<?php echo $form->error($model,'car_seat_belt'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'diet_info'); ?>
		<?php echo $form->textField($model,'diet_info'); ?>
		<?php echo $form->error($model,'diet_info'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'drug_iv'); ?>
		<?php echo $form->checkBox($model,'drug_iv'); ?>
		<?php echo $form->error($model,'drug_iv'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'second_hand_smoker'); ?>
		<?php echo $form->checkBox($model,'second_hand_smoker'); ?>
		<?php echo $form->error($model,'second_hand_smoker'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_quit_drugs'); ?>
		<?php echo $form->textField($model,'age_quit_drugs'); ?>
		<?php echo $form->error($model,'age_quit_drugs'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'alcohol_liquor_number'); ?>
		<?php echo $form->textField($model,'alcohol_liquor_number'); ?>
		<?php echo $form->error($model,'alcohol_liquor_number'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'eats_alone'); ?>
		<?php echo $form->checkBox($model,'eats_alone'); ?>
		<?php echo $form->error($model,'eats_alone'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_quit_drinking'); ?>
		<?php echo $form->textField($model,'age_quit_drinking'); ?>
		<?php echo $form->error($model,'age_quit_drinking'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sex_oral'); ?>
		<?php echo $form->textField($model,'sex_oral'); ?>
		<?php echo $form->error($model,'sex_oral'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'home_safety'); ?>
		<?php echo $form->checkBox($model,'home_safety'); ?>
		<?php echo $form->error($model,'home_safety'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_start_drinking'); ?>
		<?php echo $form->textField($model,'age_start_drinking'); ?>
		<?php echo $form->error($model,'age_start_drinking'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'first_sexual_encounter'); ?>
		<?php echo $form->textField($model,'first_sexual_encounter'); ?>
		<?php echo $form->error($model,'first_sexual_encounter'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'smoking'); ?>
		<?php echo $form->checkBox($model,'smoking'); ?>
		<?php echo $form->error($model,'smoking'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sex_anal'); ?>
		<?php echo $form->textField($model,'sex_anal'); ?>
		<?php echo $form->error($model,'sex_anal'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'age_start_smoking'); ?>
		<?php echo $form->textField($model,'age_start_smoking'); ?>
		<?php echo $form->error($model,'age_start_smoking'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sexual_partners_number'); ?>
		<?php echo $form->textField($model,'sexual_partners_number'); ?>
		<?php echo $form->error($model,'sexual_partners_number'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'car_revision'); ?>
		<?php echo $form->checkBox($model,'car_revision'); ?>
		<?php echo $form->error($model,'car_revision'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'motorcycle_rider'); ?>
		<?php echo $form->checkBox($model,'motorcycle_rider'); ?>
		<?php echo $form->error($model,'motorcycle_rider'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'helmet'); ?>
		<?php echo $form->checkBox($model,'helmet'); ?>
		<?php echo $form->error($model,'helmet'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'alcohol_beer_number'); ?>
		<?php echo $form->textField($model,'alcohol_beer_number'); ?>
		<?php echo $form->error($model,'alcohol_beer_number'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'traffic_laws'); ?>
		<?php echo $form->checkBox($model,'traffic_laws'); ?>
		<?php echo $form->error($model,'traffic_laws'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'sleep_hours'); ?>
		<?php echo $form->textField($model,'sleep_hours'); ?>
		<?php echo $form->error($model,'sleep_hours'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'alcohol_wine_number'); ?>
		<?php echo $form->textField($model,'alcohol_wine_number'); ?>
		<?php echo $form->error($model,'alcohol_wine_number'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'diet'); ?>
		<?php echo $form->checkBox($model,'diet'); ?>
		<?php echo $form->error($model,'diet'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'anticonceptive'); ?>
		<?php echo $form->textField($model,'anticonceptive'); ?>
		<?php echo $form->error($model,'anticonceptive'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'prostitute'); ?>
		<?php echo $form->checkBox($model,'prostitute'); ?>
		<?php echo $form->error($model,'prostitute'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'salt'); ?>
		<?php echo $form->checkBox($model,'salt'); ?>
		<?php echo $form->error($model,'salt'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'drug_usage'); ?>
		<?php echo $form->checkBox($model,'drug_usage'); ?>
		<?php echo $form->error($model,'drug_usage'); ?>
	</div>

	<div class="row buttons">
		<?php echo CHtml::submitButton($model->isNewRecord ? 'Create' : 'Save'); ?>
	</div>

<?php $this->endWidget(); ?>

</div><!-- form -->